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Libby MachtKNH413 MatuszakDue 1/29/2013Case Study 1: Peptic Ulcer DiseaseList all the food items that may contribute to GG’s condition and explain why.The food items that may contribute to GG’s condition include the high fat foods, fried foods, coffee, chocolate, and caffeine (cola). Coffee and cola are acidic beverages and the cocoa in chocolate is an acidic food, all of which can cause irritation of the gastric lining. High fat foods also increase inflammation.Nutrition Therapy & Pathophysiology p. 361-363List any additional oral intake that may have contributed to GG’s condition and explain why.Additional oral intake of concern includes alcohol and aspirin (acetylsalicylic acid). Alcohol can cause irritation in the gastric lining and NSAIDS assist in control of inflammation but inhibit the protective function of prostaglandin release for the gastric mucosa.NT&P p. 361-363List the non-oral stimulants (physical or psychological stress) that could contribute to GG’s condition and what she could do to change them.Cigarette smoking and stress also contribute to GG’s condition because they are factors that decrease the blood supply. Stress in GG’s daily life seems to come from personal finances, single-parent child rearing, nontraditional student college course work, employment and her son’s behavioral disorder (ADHD). These factors contribute to her stress which in turn increases stomach acid, contributing to the pain of the irritated mucosal lining. GG should be encouraged to engage in relaxation techniques she considers enjoyable and realistic. Examples could include yoga, tai chi and meditation. While many of her stressors are out her control, making a schedule and plan for each day may be the best way to help GG gain back control of her situation and give her strategies to improve her mental/physical health.NT&P p. 361; “Gastritis” UMMList the symptoms of GG’s gastritis.Symptoms of gastritis include belching, anorexia, abdominal pain, vomiting and in severe cases bleeding and hematemesis. GG displays symptoms of indigestion and abdominal pain (radiating to the lower right quadrant and up her chest). This is evident with patient reports of pain as well as her use of antacids and aspirin to quell the pain.NT&P p. 361; “Gastritis” UMMWas the bland diet necessary? Explain and list the principles of the diet plan that you think GG should follow.While changes should definitely be made to GG’s diet, a bland diet is not necessary. The University of Maryland Medicine finds that “doctors now know that a bland diet isn’t required.” However, the principles she should follow include avoiding the irritants causing her gastritis including alcohol, tobacco, and acidic beverages/foods. She should avoid coffee and cola due to the acid content of these beverages as well as the acidic cocoa in chocolate. She also should avoid high fat foods, as studies have indicated that such foods increase inflammation of the stomach lining.“Gastritis” UMMWhat is the mechanism of action of the following medications GG is receiving: Carafate, AlternaGel, and Pepcid?Carafate (also known as sucralfate) is indicated for short-term use for treatment of active duodenal ulcers. AlternaGel is aluminum hydroxide which works as an antacid to relieve heartburn or indigestion. They are recommended to take 1 hour before or 2 hours after taking other meds due to blocking their absorption. Pepcid is an H2 blocker that reduces gastric acid secretion.“Gastritis” UMM; FDA drugsList the nutrient-drug interactions that are associated with these medications.Carafate should be administered at 1 gram four times a day (this corresponds to her prescription 1g q6h on an empty stomach. It is also recommended that antacids should not be taken within one half hour before or after Carafate. No nutrient interaction was noted yet patients should take Carafate separately from other drugs.FDA DrugsAlternaGel contains aluminum hydroxide which can bind to phosphorus in food. Over time, phosphorus is prevented from bone absorption and usage and can cause depletion leading eventually to muscle weakness or even osteomalacia.HermannPepcid can be taken with or without food. Caffeine products and alcohol should be avoided because they may irritate the stomach and make it more difficult to heal.Anderson & Roach What are GG’s IBW and percent IBW?At height of 5’2”, her ideal body weight is 100# for the first 5’ plus 5# per 1” above that, or IBW = 110#. Her percent IBW is 98# / 110# = 89% IBWEstimate her daily needs using the Harris-Benedict equation and appropriate stress factor.REE female = 655.1 + (9.6 x wt) + (1.9 x ht) – (4.7 x age)REE = 655.1 + (9.6 x 44.5 kg) + (1.9 x 157.5 cm) – (4.7 x 27 years) = 1254.651250 kcal x 1.2 activity factor out of bed x 1.2 stress factor for infection = 1800 kcal.NT&P pp. 241, 688What might be the cause of the LUQ pain along with her usual pain?The elevated enzymes in her laboratory results were ALP (alkaline phosphatase) and amylase. Amylase is in the pancreas, liver, fallopian tubes and small intestine. The tissue of her small intestine is inflamed which can elevate amylase levels in the blood. Alkaline phosphatase is found in the liver, bone, placenta and intestine. Inflammation of the intestine can increase levels of ALP in the blood. The esophagogastroduodenoscopy found gastritis superior to the pyloric sphincter with an ulcer on the dorsal wall of the duodenum just below the pyloric sphincter. The left upper quadrant includes the left lobe of the liver, the stomach, spleen, upper lobe of the left kidney, pancreas, splenic flexure of the colon, and a section of the transverse colon and descending colon. Pain in the gastritis and ulcer area just below the stomach would fit into the left upper quadrant.Free Medical DictionaryIn the second set of lab values, glu, BUN, Cr, ser alb, Na, K, Cl, hgb, and hct all dropped. This probably means that GG was:C. Dehydrated when the first labs were drawn.In the second set of lab values, serum amylase, AST, and ALT all dropped. This probably means that:A. Enzymes were elevated due to alcohol. These enzymes correlate to liver function.Refer to the two lab tables again, note that two days after admission, GG’s Alk Phos and CPK remained essentially unchanged. Why?A. These enzymes are not affected by alcohol or hydrationWhat diagnostic test(s) (not lab values) indicate(s) that GG has an ulcer?The esophagogastroduodenoscopy test indicated the site of gastritis and location of the ulcer. The biopsy of tissue proved positive for H. pylori infection. These tests confirmed GG’s ulcer.Case Study p. 103Briefly sketch the anatomical position where GG’s ulcer can be found.Define H2 antagonist and proton pump inhibitor.H2 antagonist: a medication that interrupt the production of acid in the stomach; also known as H2 blockers.Proton pump inhibitor: a class of medications that block the H+, K+-ATPase enzyme, a component in HCl production, and hence reduce acid secretion in the stomach.NT&P p. G-11,22What is the mechanism of action of the following medications GG is receiving: Nexium, amoxicillin, and clarithromycin?Nexium is a proton pump inhibitor to decrease gastric acid secretion by blocking the H+, K+-ATPase enzyme. Amoxicillin and clarithromycin are antibiotics to treat the bacterial H. pylori infection.“Gastritis” UMMGG was not receiving counsel at the time the major bleeding started. If you had the opportunity to counsel GG just before the bleeding, in what areas would you feel competent to counsel her and in what areas would you refer her to someone else? Investigate the agencies in your area that are able to provide assistance to someone like GG.I would feel confident in counseling GG on strategies for health including eating right, resisting smoking, alcohol and aspirin use as well as strategies to relax and reduce overall stress. However, I would refer her to more qualified professionals to handle her monetary, childcare and divorce stressors. Agencies in Ohio would be important to research and share with GG. Family counseling services are offered through and Family & Community Services Inc. (). Smart Money Community Services offer financial services and economic education to underserved individuals in the Cincinnati area (smart-). I would also direct her to the Ohio Council of Behavioral Health & Family Services Providers and other resources listed at mentalhealth.. What is the significance of the dark stools?Blood will darken stools and is indicative of active bleeding from the ulcer.NT&P p. 362Give the pathophysiology for the cause of the following abnormal values: BUN, NH3, and WBC.BUN is blood urea nitrogen used to monitor kidney function. Urea is made in the liver when proteins are broken down. Urea is excreted through the urine once the kidneys filter the blood. Dehydration can cause BUN levels to increase because of the decreased blood flow to the kidneys.WebMD Blood Urea NitrogenNH3 is ammonia used to monitor liver function. Ammonia is formed as protein breaks down by bacteria in the intestines. Liver converts ammonia into urea to eliminate as urine. High values of ammonia in the blood can indicate severe bleeding form the stomach or intestines.WebMD Ammonia TestWBC is white blood cell count is a general test for immunity and detection of infection. The body’s natural response to infection is to increase the level of white blood cells in order to fight off the infection. H. pylori bacteria and intestinal inflammation would elevate white blood cell count.GG was probably dehydrated on admission since she had been drinking. This means that some of her lab values were probably higher or lower than indicated?Lower. Reduced volume of water in the body and blood would increase concentrations of certain substances in the blood. Proper hydration would reveal lower results for some of the values.After admission GG received packed cells and IV fluids. How would that affect the next set of lab values?Lab values should decrease and most should return to the normal range. This is similar to the effect of the first labs at her first admission compared to labs taken after receiving fluids the first time in the ER. Define the following terms:Packed cells: volume of blood cells in a sample of blood after centrifuged in hematocrit; normally 45% of the blood sampleAbdominal tap: also known as paracentesis, a test where a needle is placed through the skin of the abdomen into an area of fluid buildup. Fluid is withdrawn and collected for analysis to diagnose infection, detect cirrhosis/cancer, and/or to remove ascetic fluidPerforated ulcer: a break in the integrity of the ulcer tissueFistula: an abnormal opening or passage between two internal organs or from an internal organ to the surface of the bodyExploratory laparotomy: surgery done under anesthesia to open the abdomen and look at organs and structuresBillroth I: a surgical operation involving the excision of the pylorus and antrum and partial closure of the gastric end with the end-to-end anastomosis of stomach and duodenum.Vagotomy: severing of the vagus nerve; often a component of gastric surgeryNT&P glossary; mediLexicon dictionary; Eastern Idaho Regional Medical CenterSketch a Billroth pare a Billroth I to a Billroth II as to anatomical changes as well as to dietary changes if any.A Billroth I is the removal of part of the stomach (partial gastrectomy) with reconstruction where the top half of the stomach is reconnected to the duodenum. A Billroth II is the removal of part of the stomach (partial gastrectomy) with a reconstruction where the proximal end of the jejunum is attached to the distal end of the stomach. The duodenum is bypassed. The duodenum is the site of absorption for many nutrients also absorbed in the jejunum, but solely responsible for copper and selenium. Fat soluble vitamins (A, D, E, and K) and calcium are absorbed primarily in the duodenum and jejunum. Vitamin B12 requires intrinsic factor which is affected by gastric surgery and a vitamin B12 deficiency is common.NT&P p. 364-365Calculate GG’s energy and protein needs.Surgery changes her energy by increasing the stress factor to 1.3 and protein for major surgery to 1.2-1.5 g protein/kg.REE = 655.1 + (9.6 x 44.5 kg) + (1.9 x 157.5 cm) – (4.7 x 27 years) = 1254.651250 kcal x 1.2 activity factor x 1.3 stress factor for surgery = 1950 kcalBecause serum albumin was lower than the reference level and she was losing weight, a protein factor of 1.4-1.5g/kg can be used. Protein = 1.4 g/kg x 44.5 kg = 62 g. 1.5 g/kg x 44.5 kg = 67 g.Protein needs are about 65g, or 13% kcals.NT&P p. 688List the principles of a post-gastrectomy diet and briefly describe the scientific basis for each principle.Prescribe adequate energy and protein. Protein and energy needs will be elevated compared to that of the U.S. Dietary Guideline recommendations. This will ensure proper healing and recovery post op. A slow progression of solid food should be encouraged, simple sugars should be avoided (completely at first), and meals should include protein, fat and complex carbs. This will help prevent the onset of early and late dumping syndromes. Dairy products should be avoided because patients are often lactose intolerant post op. Calcium and vitamin D should be supplemented. Drink liquids between meals. They facilitate rapid movement through the digestive system so limiting them at meals will reduce effects of dumping syndrome. Eat five to six small meals each day and lying down after eating when possible. Vitamin and mineral supplements should be initiated and nutritional education to promote optimal nutrition and prevent deficiencies should be provided.NT&P p. 366-367Is it possible that GG’s diet will ever change or do you believe she will be on a post-gastrectomy diet for the rest of her life? Explain your answer.Due to the permanence of her gastric resection, GG’s diet should always consist of multiple small meals and liquids between them. Simple carbohydrates should be avoided. The lactose intolerance may just be initially after surgery and dairy food items can slowly be reintroduced. Protein should still always be included in every meal and snack to help reduce the speed of movement through the GI tract. NT&P p. 367-368If GG were to be hospitalized for an extended period of time and required a tube feeding via duodenum or jejunum, what characteristics would be appropriate for the tube feeding you would use?In selecting a formula due to impaired digestion and absorption, a tube would be placed via the duodenum or jejunum and would need to be hydrolyzed. Protein and energy needs would be high. A formula with high kcal, high protein, and wound healing would be appropriate. Lactose-free formulas would also be most appropriate. Examples of hydrolyzed high kcal, lower carbohydrate, high protein and lactose free formulas include Crucial and Pivot 1.5 Cal.NT&P pp. 86, A-101Using the table below, compare several of the enteral nutritional supplements that would be appropriate for GG.ProductProducerkcal/mLNon-pro kcal/g Ng/LNa (mg)K (mg)mOsm/ kg waterg fiber/LFree H20/ L in mLProCHOFatCrucialNestle1.5067:1941346811681872490*772Pivot 1.5 CalAbbott1.5075:19417251140020005957.5692NT&P p. A-101, Abbott Nutrition. (*Fiber content could not be found for Nestle Crucial)ReferencesAnderson, J. & Roach, J. (2008). Nutrient-drug interactions and food. Colorado State University Extension. Retrieved from disorders health center: Ammonia test. (2011). WebMD. Retrieved from digestive-disorders/ammonia-testDrugs. (n.d.). U.S. Food and Drug Administration. Retrieved Jan. 27, 2013 from . (2011). University of Maryland Medical Center. Retrieved from articles/gastritis-000067.htmHermann, J. (n.d.). Drug-nutrient interactions. Oklahoma State University Cooperative Extension Service. Retrieved Jan. 27, 2013 from and resources: Blood urea nitrogen. (2010). WebMD. Retrieved from . (2009). Eastern Idaho Regional Medical Center. Retrieved from info/paracentesis-abdominal-tap-Pivot 1.5 cal. (2012). Abbott Nutrition. Retrieved Jan. 28, 2013 from Products/pivot-1_5-cal ................
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